PENANGANAN REAKSI

TRANSFUSI DARAH
Andhika Rachman
Divisi Hematologi-Onkolog Medik
Departemen Ilmu penyakit Dalam
FKUI RSCM
The
immunological
reaction
towards blood
transfusion
sometimes
causes clinical
symptoms.

Figure 1. Cumulative numbers of cases reviewed by SHOT (Serious Hazards of Transfusion), the UK hemovigilance
system 1996-2007 (n = 4335). ATR (Acute Transfer Reactions) ; HTR (Hemolytic Transfusion Reaction) ; IBCT
(Incorrect Blood Component) ; PTP (Post Transfusion Purpura) ; TA-GVHD (Transfusion-Associated Graft-Versus-Host
Disease) ; TRALI (Transfusion Related Acute Lung Injury) ; TTI (Transfusion Transmitted Infection).
TRANSFUSION REACTIONS
IMMUNOLOGIC

NON-IMMUNOLOGIC
IMMUNOLOGIC
TRANSFUSION REACTIONS
Hemolytic reactions due to RBC incompatibility
Febrile & pulmonary reactions due to WBC or
platelet antigen

Allergic & anaphylactic reaction due to Abs

against soluble Ags, usually plasma proteins

Graft-vs-host disease due to transfused

lymphocytes

Post-transfusion purpura
NON-IMMUNE TRANSFUSION
REACTIONS

Volume overload
Metabolic - Hyperkalemia, Hypocalcemia
Hypothermia, especially in elderly,
neonates
Coagulopathy due to dilutional effects
Rx to contaminating infectious agents
 HEMOLYTIC TRANSFUSION
REACTIONS

Immediate intravascular hemolytic tranfusion

reactions

Delayed hemolytic transfusion reactions

Intravascular Hemolytic
Tranfusion Reaction
Usually due to ABO incompatibility

IgM complement-binding antibodies

Ab to Jka, K, Fya, Rh can cause IHTR

Lysis of transfused RBCs is usual

scenario
Rarely, lysis of recipient RBCx due to Tx
of plasma containing antibodies (anti-A1)
SIGNS & SYMPTOMS OF IHTR
Abrupt onset
Fever with or without chills
Chest or back pain
Anxiety and Dyspnea
Tachycardia and hypotension shock
Intravascular coagulation
Hemoglobinuria & Acute Renal Failure
IHTR suspected :
IMMEDIATELY stop the transfusion

IHTR severity related to volume of RBCs given

30 ml of incompatible RBCs may be lethal

Most severe IHTR caused by > 200 ml RBCs

Mortality rate for severe IHTR is 40%

MANAGEMENT OF IHTR
Notify Blood bank, send blood bag & blood
samples

Hydration- maintain BP, urine flow@ 100ml/hr.

Furosemide or mannitol to maintain urine flow

Assess & treat for coagulopathy

Monitor renal function

Delayed Hemolytic
Transfusion reactions
Usually milder than IHTR

Predominantly extravascular hemolysis

Occurs 2-10 days post-transfusion

Major causes: Abs to Jka, Rh (E, c, D)

Less commonly, Abs to K, Fya

10-25 % pts have > allo-antibody

MANAGEMENT OF DELAYED
HTR
Notify BB, send requested blood samples

Maintain hydration

Once Ab is known, patient needs card identifying the

presence of the specific allo-antibody
Sign & Symptoms of Delayed
hemolytic transfusion reaction

Fever

Abrupt drop in hemoglobin

Jaundice

Can have hemoglobinuria & hemoglobinemia

Febrile, Non-Hemolytic
Transfusion Reaction
More common in multiply transfused pts

Occurs in 0.5% - 3% of transfusions

Due to Alloimmunization to WBC & platelet antigen

Can be due to cytokines (usually develop in platelet

concentrates, in-vitro)

Can be due to transf of bacteria, bacterial toxins

Signs & Symptoms
Febrile Transfusion Reactions
Chill, followed by fever, during or soon after Tx

Headache

Malaise

Sometimes, with urticaria

Usually mild

Resolve within a few hours

Management of Febrile
Transfusion Reaction

Stop the transfusion

Notify BB & send requested samples

Consider the possibility of a hemolytic transfusion rx

Evaluate for sepsis

Meperidine for rigors, acetaminophen & HC

Antihistamines, if urticaria

Prevention - leukodepleted blood after 2 febrile

transfusion rx
Transfusion-Related Acute Lung
Injury
Acute onset respiratory distress

Due to Tx of plasma with Abs against recipient

granulocyte-specific or HLA Ags

Agglutination of granulocytes & complement

activation in lung vasculature

Capillary leak syndrome, resembles ARDS

Occurs 1 in 5000 transfusions

Transfusion-Related Acute Lung
Injury

Occurs within a few hours of transfusion

Chills, fever, chest pain, sometimes hypotension

CXR shows florid pulmonary edema

Subsides in 48-96 hours, with supportive care

Respiratory support for hypoxia ( O2, ventilator)

High doses of corticosteroids can be helpful

Hemodynamic monitoring may be needed

Allergic Reactions to Plasma
Occurs in 1-3% of transfusions

Mild urticaria, other types of rash

Can see bronchospasm, angioedema

Anaphylaxis - very rare

Related to dose of plasma infused

anti-IgA in IgA-deficient pts (1/400-1/500 nl

people are IgA def, 20-25% have a-IgA)
Post-Transfusion Purpura
Severe thrombocytopenia 5-10 days post-Tx

Alloantibodies against plt-specific antigens

Usually anti-HPA-1a

Occurs in pts sensitized by prior Tx, pregnancy

Rx with IVIG, Plasma Exchange, Steroids

ACUTE TRANSFUSION
REACTION
TYPES OF TRANSFUSION
REACTIONS
Acute
Allergic Delayed
Febrile Alloimmunization
Hemolytic Hemolytic
Anaphylactic Transmissible
Bacterial Contamination Diseases
(Sepsis) Graft vs Host Disease
Circulatory Overload Iron Overload
Transfusion Related Post Transfusion
Acute Lung Injury Purpura
(TRALI)
Definition
Acute Transfusion Reaction:
Reactions occurring at any time up to 24 hours
following a transfusion of blood or components.
The Most Common Cause of Acute
Immediate Intravascular Hemolysis

Failure to identify the patient with the donor unit at the time
of administration

Collecting pre-transfusion specimen from the wrong patient

Incorrectly labeled specimens
Unlabeled specimens that are labeled after leaving the bedside
(in the lab or at the nursing station)
Immediate Actions to Take
1. Stop the Transfusion
2. Notify the attending physician and the laboratory
immediately
3. Do clerical check at bedside of identifying tags and
numbers
4. If symptoms are urticaria and pruritis only, consider
administering antihistimine
If symptoms disappear continue transfusion

5. If additional symptoms or hives and itching do not

disappear discontinue transfusion
6. Collect blood specimen and first voided urine
Immediate Actions to Take
7. Treat patient symptoms
as per physician instructions
Take vitals
Pulse
Temperature
Blood Pressure

8. Document thoroughly
Complete reaction form
Send form, bag, tubing and set to laboratory
Risk of Suffering a Transfusion
Reaction
RBC Alloimmunization: 1-2%
Febrile Non-Hemolytic
to Platelets: 20-30%
to RBC: 1%

Allergic (mild): 1-3%

Circulatory Overload: 1%
Acute Hemolytic: 1:12,500
Fatal: 1/600,000

Anaphylaxis: 1/25, 000

COMPLICATION OF
BLOOD TRANSFUSION
Local Complication: Common Complication:
- Failure to gain vein access - Reactions of Blood
Transfusion
- Vein fixation are not good - Infection / Transmission of
- Problem in Puncture Place Infectious Diseases
- Veins burst when punctured - Immunological
Sensitization
- etc - Haemochromatosis
- etc
REACTIONS OF BLOOD
TRANSFUSION
If laboratory tes conducted pre- blood transfusion, majority blood
transfusion does not give side effects to the patient.

However, sometimes appear reaction in patients, although

laboratory tes already conducted and the results Compatible (=
means match between blood recipient and donor).

Reaction: Light Reaction (Increased temperature, headache) until

Heavy (Hemolysis reaction) and may even die.
REACTIONS OF BLOOD
TRANSFUSION
The most often appear :

Febrile reactions

Allergic reactions

Hemolytic reactions
FEBRILE REACTIONS
Headache Shivering and shaking Sudden temperature
arise

Heavy reaction rare

Response toward medication

Fever with or without chills is the result from the generation

of pro-inflammatory and anti- inflammatory cytokines of
which pyrogens such as TNF-a act upon the temperature
centre in the hypothalamus
ALLERGIC REACTION
Heavy allergic reaction (anaphylaxis) : rare

Skin urticaria, bronchospasm moderate, edema

larings : rapid response to treatment

Skin reactions with or without wheezing

suggest IgE antibodies and mast cell activation
in the recipient
HEMOLYTIC
Hemolytic as wellREACTION
as non-hemolytic transfusion reactions are
associated with the generation of such pro-inflammatory
cytokines, either activated in-vivo by the immune reaction w6x,
or produced in vitro during storage of blood components.

Started by reaction :
Antibodies in the serum of patients >< Antigen
corresponding to erythrocytes donor
Antibodies in donor plasma >< Antigen corresponding
in erythrocytes of patients

Hemolytic Reaction :
Intravascular
Extravascular
 Intravascular Reaction

Hemolysis in blood circulation

Jaundice and hemoglobinemia

IgM antibody

The danger of anti-A and anti-B specific of the

ABO system

Fatal due to uncontrolled bleeding and renal

failure
 Extravascular Reaction:

Rarely as great as intravascular reaction

Rare fatal reactions

Due to the destruction of IgG antibodies

erythrocytes via macrophages

Lead to sudden drop in Hb levels until 10 day

post transfusion
 Because the majority of immunological transfusion
effects do not cause clinical manifest reactions,
another categorisation can be:

1. The transfused components are prematurely

destroyed

2. Donor immunity against the recipient

3. The recipients immune system undergoes

unintended alterations.
Table 5. Acute Transfusion Reactions (1)

Type Sign and Symptoms Usual Cause Treatment

Prevention

Intravascular Hemoglobinemia and ABO incompatibility Stop transfusion;

Avoid clerical
hemolytic hemoglobinuria, fever, (clerical error) or other hydrate, support
errors; ensure
(immune) chills, anxiety, shock, DIC, complement fixing blood pressure & proper
sample
dyspnea, chest pain, antibody causing respiration; induce & recipient
flank pain, oliguria antigen antibody diuresis; treat shock
identification incompatibility and DIC, if present

Extravascular Fever, malaise, indirect IgG Monitor Ht,

Avoid clerical
Hemolytic hiperbilirubinemia, Non-complement renal & hepatic error :
ensure
(immune) increased urine urobili- fixing antibody often function, coagulati proper
sample
nogen, falling hematocrit assoclated with on profile, no acute &
recipient
delayed hemolysis treatment generally identification
required

Febrile Fever, chill, rarely Antibodies to Stop transfusion; Pre

transfusion hypotension leukocytes or plasma give
antipyretic; antipyretic; (continued)
Table 5. Acute Transfusion Reactions (2)

Type Sign and Symptoms Usual Cause Treatment Prevention

Allergic (mild Urticaria (hives), rarely Antibodies to plasma Stop transfusion; Pre-
transfusion
To severe) hypotension or anaphy- proteins; rarely anti- give; antihistamine
antihistamine;
laxis bodies to IgA (PO or IM); if severe, washed RBC
epinephrine and/or components, If
steroids recurrent or severe check pre-
transfusion IgA
levels in patients
with a history of
anaphylaxis
to transfusion

Hypervolemic Dyspnea, hypertension Too rapid and/or Induced diuresis; Avoid

rapid or
pulmonary edema, excessive blood phlebotomy;
excessive
cardiac arrhytmias transfusion support cardio-
transfusion
respiratory system
as needed

(continued)
Table 5. Acute Transfusion Reactions (3)

Type Sign and Symptoms Usual Cause Treatment Prevention

Transfusion- Dyspnea, fever HLA or leukocyte Support blood

Leukocyte-reduced
related acute pulmonary edema, antibodies; usually pressure and RBCs if
recipient
lung injury hypotension, normal donor antibody respiration (may has the
antibody;
(TRALI) pulmonary capillary transfused with require intubation) notify
transfusion
wedge pressure plasma in compo service to
quaran-
nents tine remaining
components from
donor

Bacterial Rigors, chills, fever, Contaminated Stop transfusion; Care in

blood
sepsis shock blood component support blood collection
and
pressure; culture storage; careful
DIC = disseminated intravascular coagulation;patient
IV = intravenous;
and blood IM = to arm-
attention
intramuscular; PO = by mouth;RBC = red blood cells
unit; give antibiotics preparation for
; notify blood trans- phlebotomy
fusion service
 Table 4. Workup of an Acute Transfusion Reaction
n acute transfusion reaction occurs :

Stop blood component transfusion immediately

Verify the correct unit was given to the correct patient
Maintain IV access and ensure adequate urine output with an appropriate crystalloid or colloid solution
Maintain blood pressure, pulse
Maintain adequate ventilation
Notify attending physician and blood bank
Obtain blood / urine for transfusion reaction workup
Send blood bag and administration set to blood transfusion service immediately
Blood bank performs workup of suspected transfusion reaction at follows :
a. Check paper work to ensure correct blood component was transfused to the right patient
b. Evaluate plasma for hemoglobinemia
c. Perform direct antiglobulin set
d. Repeat other serologic testing as needed (ABO/RH)

travascular hemolytic reaction in confirmed

Monitor renal status (BUN, creatinine)

Initiate a diuresis
Analyze urine for hemoglobinuria
Monitor coagulation status (prothrombin time, partial tromboplastin time, fibrinogen, platelet count)
Monitor for sign of hemolysis (lactate dehydrogenase, bilirubin, haptoglobin, plasma hemoglobin)
Repeat compatibility testing (cross match)
If sepsis is suspected, culture unit and patients, and treat as appropiate

Adapted from snyder EL. Transfusion reaction. In : Hoffman R, Benz. EF Jr, Shattil SJ, et al. Hematology : Basic
Principle and practice, 2nd ed. Ney York : Chruchill Livingstone, 1995 ; 2045-53
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